Gastroenterology Flashcards
3 month old boy with constipation since birth, FTT, and a mildly distended abdomen with no stool on rectal exam. What would be the most appropriate next test:
a. rectal biopsy r/o hirshsprung
b. TSH
c. Sweat chloride (CF usually have meconium ileus)
d. follow up in 6 months
TSH
in this case HYPOTHYROIDISM is MORE COMMON then hirshprung, and the QUESTION is not what is the most likely diagnosis that would reveal the diagnosis (then you would pick rectal bx)
cannot assume
remember no soy if on levothryoxine
. 12 month old child who has passed 3 soft red stools in the past 12 hours. He is asymptomatic. The same thing happened 4 months ago but resolved. His Hb is now 70. Investigation?
a. Upper endoscopy
b. UGI series
c. Nuclear med scan for ectopic gastric tissue
c. Nuclear med scan for ectopic gastric tissue
6 month boy with loose stool and irribitle BF intially and then solids introduced at 4 month of age. Mucus is apparent in stool. What is most lkely DIAGNOSIS?
a- Celiac
b- Cystic fibrosis
c- Cow milk protein allergy
CMPA
BUT IF it said having FTT then you think celiac, ALSO CMPA more likely then CELIAC
CMPA does not typically cause FTT, therefore use that as a deciding factor
You see a teenager in your clinic with progressive dysphagia to solids and epigastric pain. He has been diagnosed with eosinophilic esophagitis, and a referral has been sent for allergy testing. In the meantime, what should you do?
a) Elimination diet
b) Oral fluticasone by MDI
c) Proton-pump inhibitor → treat potential GERD in the mean time until you see allergy
d) Oral Prednisone
c) Proton-pump inhibitor → treat potential GERD in the mean time until you see allergy
- A 6-week old boy has begun having loose stools, some of them blood-tinged. Exclusively breastfed. Which is most likely?
a, Meckel’s
b. Food protein-induced proctocolitis
c. Infectious colitis
Food protein-induced proctocolitis
Child with acute otitis media is taking amoxicillin and has two episodes of bloody diarrhea, Is otherwise afebrile and well. Besides discontinuing the current antibiotic, what else would you do to manage this child? a-Close follow up b PO metronidazole c PO vancomycin d PO clindamycin
a- close fu
if mild - can stop abx and follow up
moderate - tx with oral metrond
sever - oral vanco (never IV)
if toxic megacolon or sepsis then oral vanco and IV metro
Description of a 2 month old baby with colic. Tolerating breastfeeding well, normal exam. What is the best management?
- Encourage mom to continue breast feeding
- Add cows milk based formula in diet
- Add soy based formula in diet
- Simethicone
Encourage mom to continue breast feeding
As is the case for most self-resolving conditions without a known cause, counseling is the most effective treatment. However, multiple interventions with minimal effectiveness are often tried, and these often involve the gastrointestinal tract: elimination of cow milk from the breastfeeding mother’s diet, formula changes (to soy or to protein hydrolysates), or a trial of herbal tea or simethicone to decrease intestinal gas. Medications such as antispasmodics are not recommended because of the risk for side effects. Other sensory modifiers (e.g., car rides, massage, swaddling) are also attempted to provide some course of action until the expected 3- to 4-month resolution.
What is the utility behind a fecal calprotectin?
- To differentiate between functional abdominal disorder and IBD.
- To differentiate between IBS and IBD
- To determine the severity of inflammation in IBD
- To diagnose post infectious IBS
differntaite btwn IBS and IBD
Fecal calprotectin levels are elevated in inflammatory intestinal diseases, and may be useful for distinguishing inflammatory gastrointestinal disease including IBD from noninflammatory causes of chronic diarrhea (such as functional abdominal pain)
Child with 5 vomiting episodes over the last 12 months, associated with pallor, lasting 2-3 hours. Between episodes she is other well, growing and thriving, with a normal examination. What do you want to do:
- Reassure
- Refer to gastroenterology
- Neuroimaging
- Start PPI
Refer to gastroenterology
Safer to refer to gastro. Cyclic vomiting a diagnosis of exclusion.
If mention of a headache or any other worrisome neuro sx, then get neuroimaging
A 7yo boy has been complaining intermittently over the last 2 days of abdominal pain and has had non-bilious emesis. He has had several dark red mucousy stools. He is tender on palpation over the RUQ. Which imaging test would reveal the diagnosis?
- UGI
- Technetium 99 scan
- Abdo U/S
- Colonoscopy
- Abdo U/S
Child referred to you with suspicion of celiac disease. Had anti-TTG done, which was negative. What is your next step. Refer to GI Endoscopy with biopsy Anti-gliadin antibodies Measure IgA
IgA
8 year old girl with epigastric discomfort for many months, progressively getting worse and now waking her up at night time. Her father has peptic ulcer disease, and she has in fact tried his antacids with some relief. What should you do?
Reassure, she can use the antacid as needed
Treat empirically with PPI, amoxicillin, clarithromycin
Urea breath test
Esophagoduodenoscopy with biopsy
Esophagoduodenoscopy with biopsy
According to lecture: reasonable to start with antacids/PPI, since nocturnal symptoms ongoing with only some relief, need to do investigations. In children need to confirm H. pylori infection with endoscopy and biopsies before starting treatment
First line treatment = triple therapy with PPI (omeprazole) + clarithromycin + amoxicillin
Can have resistance to clarithro, guidelines are changing
8 year old boy with gastroesophageal reflux for the last 4 years, now having dysphagia on solids. Which of the following tests would reveal the diagnosis?
a. UGI
b. Upper scope + biopsy
c. Abdominal ultrasound
d. AXR
UGI
Likely prolonged reflux causing progressive stricture
13yo F in foster care has been losing weight, decreased appetite, and occasional emesis. On exam you see that she is pale and has patchy areas of hair loss. What is the most likely diagnosis?
a. Trichobezoar
b. Anorexia nervosa
c. Celiac disease
d. Lead poisoning
a. Trichobezoar
You have developed a treatment plan for a 3 year old boy with constipation including treating with PEG 3350. How long do you need to treat for?
a. 1 week
b. 3 days
c. 6 months
d. 1 year
6 months
In a patient with liver failure, which of the following is most concerning regarding need for transplantation?
a. Acute onset lethargy
b. Acute liver volume loss
c. Increase in liver enzymes
b. Acute liver volume loss
A neonate has an elevated conjugated bilirubin. What is your next step in management?
a. Liver biopsy
b. Abdominal ultrasound with Doppler
c. HIDA scan
d. Repeat liver enzymes in 2 months
AUS with dopp
r/o alagille, or biliary atresia
A 6 year old boy has recurrent vomiting episodes where he need to come to the ER and receive IV fluids. He is completely fine in between these episodes. What is the most likely diagnosis?
a. Cyclic vomiting
b. Malrotation
a. Cyclic vomiting
- A 4 year old patient presents with lethargy, bruising, hepatosplenomegaly and elevated LFT’s. He has signs of acute liver failure (this is given in the question). Which would make you most worried?
a) Sudden decrease in liver size
b) Development of asterixis
a) Sudden decrease in liver size
- Adolescent girl with scoliosis has undergone spinal surgery. She present with bilious vomiting for the last few days. What is the etiology?
a. bowel adhesions
b. superior mesenteric artery syndrome
c. malrotation with volvulus
d. pancreatitis
b. superior mesenteric artery syndrome
- Iron overdose, on dexoferoime already. Is now at 1hr post ingestion…what is the next step?
a) Endoscopy
b) Charcoal
c) WBI
d) Ipecac
WBI - whole bowel irrig
- Ipecac is no longer routinely recommended for poisoning.
- Activated charcoal is most efficacious if given within 1 hour of ingestion.
- Gastric lavage has unproven efficacy for most ingestions.
- Whole bowel irrigation is indicated for sustained-release or enteric-coated substances.
- Alkalinization of urine still considered valuable in the management of acute overdoses of salicylates, barbiturates, or tricyclic antidepressants.
- 14 yo s/p Fontan a few years ago, now diarrhea, and low albumin
a) Protein losing enteropathy
a) Protein losing enteropathy
- 5 mo Kid flexion of arms and legs, and with associated vomiting and abdo distention, sleepy after episodes. What will give diagnosis?
a) EEG
b) US abdomen
abdo US
- 15 yo boy with nocturnal diarrhea and diarrhea 3 months. No pain, tried lactose free didn’t help
a) UGI
b) Colonoscopy
c) Barium
d) Lower Scope
b) Colonoscopy
- Infant with colic
a) Try hypoallergenic milk
b) Try soy milk
c) Give probiotic
a) Try hypoallergenic milk
- 3 week old with loose stools and red blood intermixed with the stools, no FTT. What is it?
a) Anal Fissure
b) CMPA
CMPA
- Girl with facial edema, pallor. Albumin 26. Urine negative for protein. Most likely test to reveal diagnosis:
a) serum trypsinogen
b) stool alpha 1 antripsin
c) echocardiogram
d) 24 hr creatinine clearance
b) stool alpha 1 antripsin
fecal a1-antitrypsin measurement is the most useful stool marker of protein malabsorption. It is important to concomitantly measure serum a1-antitrypsin to ensure that the patient does not have a1-antitrypsin deficiency, which could result in a false-negative stool study.
8yo male. Duodenal ulcer. What is treatment? (Note: none of them listed a PPI) amox + clarithro clinda + clarithrO metronidazole + clinda bismuth subsalicylate + metronidazole
amox + clarithro
would want a PPI too
- 3 week old blood mixed with stool, has been having since 2 weeks old, normal exam, growing/thriving, formula fed
A. Anal fissure
B. Cow’s milk allergy
C. Meckel’s
Cow’s milk allergy
15yo boy presents with severe epigastric pain that worsens after eating. He has had a few episodes of non-bilious emesis. On exam he is tachycardic and has epigastric tenderness, but is otherwise stable. Blood work reveals a lipase of 1650, wbc 12.5, and normal plt, hb, lytes, renal function and ALT. What is the next best step in management?
a. NPO and IV fluids
b. Surgical consult
c. Ceftriaxone
d. IV pantoprazole
a. NPO and IV fluids
8yo boy with type 1 diabetes presents with nonspecific abdominal pain. He has had normal stools with no hematochezia. There has been a 1kg weight loss over the past 3 months. On exam he has a pruritic bullous lesions on his extensor surfaces of his arms and on his trunk. What is the most likely diagnosis?
a. Celiac disease
b. IBD
c. eosinophilic gastroenteropathy
d. parasitic infection
CELIAC
Dermatitis herpatiformis
5 month old with vomiting for 6 hours intermittently, has had 3 or 4 episodes of flexion and extension of arms and legs, drowsy after, abdomen is distended, which test would reveal diagnosis? A. EEG B. CT abdomen C. Ultrasound abdomen D. Abdominal x-ray
AUS
Intuss? - pg 1288 nelsons - most common in 3 mo to 6 yr, and abdo emergency in less then 2 y
Ultrasound sensitivity 98-100% generally and 88% for diagnosing intuss
A 3 month old male infant presents to the emergency department with a 1 month history of “spit ups” and 2 day history of projectile vomiting. His last two vomits were bilious. On exam, he looks dehydrated and unwell. His abdomen is distended, non tender, with no palpable masses. What diagnostic test would MOST likely reveal the underlying abnormality?
a. Abdominal ultrasound
b. Barium enema
c. Upper GI series
d. Abdominal X ray (anterioposterior and lateral)
a. Abdominal ultrasound
gold standard for malrotation or volvulus is upper gi. Most present within first year of life, commonly 1st month but can present with intermittent colic
You are treating a 5 year old boy for constipation. In addition to disimpaction, his mother asks you how long he will need to be treated with PEG for? 3 months 6 months Until he’s toilet trained 3 weeks
6 month
Education – of parents and child around mechanism of constipation and overflow encopresis
2) Disimpaction – with peg3350 1-1.5 g/kg/d x 3 days
3) Maintenance therapy thereafter – peg 3350 0.4-1 g/kg/d, with parents titrating to at least one soft stool daily x 6 mo
4) Behavioral modification – use of timed toileting, praise/reward, footstool for optimized position on toilet, avoiding punishment/negative reinforcement
5) Dietary modification – whole grains, fruits and veg
3 week old baby presents with poor feeding and poor weight gain. He is jaundiced and has hepatosplenomegaly. His bilirubin is 170 with conjugated 115. Which imaging would you do next? Abdominal ultrasound with dopplers HIDA scan CT abdomen MRI abdomen
Abdominal ultrasound with dopplers
If conjugated > 20% total bilirubin= cholestasis (or obstruction of bile flow).
Differential diagnosis lengthy: extrahepatic biliary atresia - most common single cause (33%).
The infant who has elevated conjugated bilirubin and cholestasis should be evaluated expeditiously to allow definitive diagnosis and surgical intervention before effective surgical drainage is precluded.
a 14 year old boy has epigastric pain, dysphagia with solids and weight loss. He is scoped and diagnosed with eosinophilic esophagitis. What management would you recommend?
Referral to Allergy for skin testing to identify potential allergens
PPI
Oral fluticasone
Oral prednisone
PPI
7 wk old baby boy who cries 5h per day and has colic, reflux with feeds; parents try soy milk, baby gets diarrhea; what do you recommend? [CPS]
a. Try 2 wks of hypoallergenic milk
b. Give PPI
c. Try probiotics
d. Try lactose free something
Try 2 wks of hypoallergenic milk
For infants with severe colic, IF concern of CMPA, an empiric time-limited (two weeks) therapeutic trial of a hypoallergenic diet could be considered
For the breastfed infant with colic where there is the relatively rare concern of a cow’s milk protein allergy, one can consider eliminating cow’s milk from the maternal diet x 2 weeks
For the bottle-fed infant with colic, rare concern CMPA, 2 week trial of an extensively hydrolyzed formula may be considered
The use of soy formulas in the treatment of infantile colic should be avoided**
Currently, evidence does not support the use of lactase in the management of infantile colic.
There is insufficient evidence to make recommendations on the use of probiotics or prebiotics
Crohn’s kid on azathioprine; present w r flank pain; stools normal. What is your dx?
a. Renal colic
b. Cholecystitis
c. Crohn’s flare
RENAL COLIC
chronic steatorrhea»_space; Fat binds to calcium, leaving oxalate free to be absorbed and deposited in the kidney, where it can form into stones. Patients w/ IBD also get uric acid stones\
Azathioprine = immunomodulatory drug used in IBD
No specific renal side effect
Most common side effects: malaise, N/V/D, leukopenia, thrombocytopenia, black box warning for malignancy, hepatotoxicity (increased transaminases), infection, myalgia, fever
7y boy with low ferritin and low hgb. Other cell lines normal, exam normal. Has been on iron treatment for 3mo with good compliance. His ferritin and hgb are still low. What is the next step?
a. Anti-TTG
b. Bone marrow
c. Upper GI
d. Upper endoscopy
a. Anti-TTG
Most common extraintestinal manifestation = iron-deficiency anemia unresponsive to iron therapy
[Nelson’s, p 1309 19th edition)
Intestinal sx in year 1-2, with FTT, vx, anorexia, muscle wasting, irritbility
Can also have osteopenia, endocrinopathy and arthritis later in life
5 years old kid w abdo pain, on u/s see intussception; has hyperpigmented macules on lips
a. Peutz jegger
b. Crohn’s
Peutz Jegher: Autosomal dominant, characterized by: [Up to date]
Multiple hamartomatous polyps in the GI tract - develop in first decade of life, 50% asymptomatic at time of diagnosis. Can present w/ obstruction caused by intussusception, occlusion caused by a polyp, pain caused by infarction, bleeding caused by ulceration
Mucocutaneous pigmentation - melanin spots, present in > 95%, most common the lips/perioral, palms/soles, buccal mucosa
Increased risk of malignancy - GI and non-GI (breast, ovary, cervix in females, sertoli cell in males)
Kid w hepatitis, which would be an indicator of function?
inr
bili
nh3
inr
A 3 week old patient is being worked up for cholestasis and is found to have a pointy chin, a broad forehead and butterfly vertebrae. Which of the following is most consistent with the diagnosis?
a. chorioretinitis
b. posterior embryotoxon
c. cataract
d. glaucoma
b. posterior embryotoxon
Alagille: part of Ddx for cholestasis, characterized by paucity of interlobular bile ducts AND:
● Chronic cholestasis (91 percent)
● Cardiac anomalies, most commonly peripheral pulmonic stenosis (85 percent)
● Butterfly vertebrae (87 percent)
● Posterior embryotoxon of the eye (88 percent)
● Dysmorphic facies, consisting of broad nasal bridge, triangular facies, and deep set eyes (95 percent)
Other manifestations: short stature, renal disease, and pancreatic insufficiency; developmental delay
AD inheritance, JAG-1 mutations (90%), NOTCH-2
- 3 month old boy with constipation sincenucle birth, FTT, and a mildly distended abdomen (RECTAL EXAM NOT DESCRIBED). What would be the most appropriate next test:
a. rectal biopsy
b. TSH
c. Sweat chloride (CF usually have meconium ileus)
d. follow up in 6 months
r/o hirshrpung with rectal bx
A 13 year old girl with intermittent cough and early morning throat pain. She also has shortness of breath with exertion. Parents comment that she has had bad breath. What would you do?
a. Upper GI
b. abdominal U/S
c. CXR
d. pH probe
ph probe
GERD
cause of malnutrition in IBD??
a. low intake of nutrients
b. Malabsorption
a - dec intake nutrient
Treatment duodenal ulcer
a. amox-clarythromycin
b. cefixime-metronidazole
a. amox-clarythromycin + PPIx14 d, and ppi x30d
or amox/flagyl and PPI
or
clarithro/flagyl + ppi
. 3 month old boy with constipation since birth, FTT, mildly distended abdomen and no stool on rectal examination. What would be the most appropriate next test:
a. rectal biopsy
b. TSH?
c. Sweat chloride
d. follow up in 6 months
rectal bx
3 month old baby boy who has been breastfeeding well, but now 3rd percentile in growth parameters. Constipated since birth.
a. TSH
b. sweat test
c. anal manometry
TSH
Kid with bloody diarrhea 1 month ago which has now resolved. Now has weight loss and abdominal pain. Which was the most likely organism?
a. Yersinia
b. Campylobacter
c. E Coli
d. shigella
YEERSINIA - micker of chrons
ecoli can cause HUS woith -157:h7
shigella - watery diarrhea
Kid with bloody diarrhea 1 month ago which has now resolved. Now has weight loss and abdominal pain. Which was the most likely organism?
a. Yersinia
b. Campylobacter
c. E Coli
d. shigella
YERSINIA - micker of chrons
ecoli can cause HUS woith -157:h7
shigella - watery diarrhea
Which is unlikely to induce remission in IBD? a- steroid b- remicaide c azithyroprine d enteral
c - azithaiprine
Teenager who has had low grade fever, malaise, and weight loss in the last 3 weeks. it started with non-bloody diarrhea x 1 week, now resolved. What is cause?
a. e coli
b. campylobacter
c. c difficile
d. yersinia
yersinia
Description of kid with butterfly vtb, heart murmur, cholestatic jaundice at 2 weeks of life), eyes show
a. chorioretinitis
b. posterior embryotoxon
c. cataract
d. Glaucoma
alagille - embryotoxin
- Kid with peptic ulcer. Hist treatment would likely include
a. amoxcil +clarithro
b. clinda and clarithro
c. flagyl and ????
amoxcil +clarithro
Child with increased unconjugated bili, increase conjugated bili, increased ALT, AST. Normal alpha1antitrysin, 1:512 anti-sm. Most likely dx?
a. Gilberts
b. Alpha 1 antitrypsin
c. PSC
d. Autoimmune
autoimm
elevated AST/ALT, elevated bilirubin, hypergammaglobulinemia (esp IgG), can get pancytopenia + prolonged INR + low albumin. Autoantibody patterns based on type: Type I (most common) = ANA, anti-smooth muscle (SM); Type II = anti-liver kidney miscrosom (LKM).
Gilbert syndrome: Decreased hepatic glucuronyl transferase a
Adolescent female presents with jaundice. Bloodwork findings: bili 55, direct 40, AST 250, ALT 200. Copper, ceruloplasmin, Hep A, B, C normal. Alpha 1 antitrypsin done (2.5 U). what is the cause?
a. alpha-1 antitrypsin
b. autoimmune hepatitis
c. Gilbert’s
b. autoimmune hepatitis
- 1 mo old baby with blood in his stool. Cause?
a. Anal fissure
b. Cows milk allergy
c. Colitis
d. Mat blood
CMPA
Maternal blood more common in the neonatal period (uptodate)
· Anal fissures are the most common cause of rectal bleeding < 1yo, however blood not typically mixed with stool, usually streaks on surface, with wiping
· CMPA – common cause of blood in stools of infants, usually presents between 2-8 weeks, resolves by 6 to 18 months, treat with extensively hydrolyzed formula or maternal elimination diet if breastfed
2 week old baby, well, with stool and blood mixed within. Cause?
a. cow milk protein allergy
b. anal fissure
c. gastroenteritis
CMPA
- Most important reason to remove a foreign body in the esophagus within 24 hours is to:
a. Decrease risk of GERD
b. Decrease risk of aspiration
c. Decrease risk of perforation
d. Risk of Esophagitis
perforation
All FB in the esophagus must be removed within 24 hours endoscopically to avoid perforation (past lecture) Most commonly ingested foreign body = coins >80% of FB will pass spontaneously without intervetion First step (after ABCs + physical exam) is to get 2 view CXR · Coin with flat face in AP = in esophagus · Flat face in lateral view = in trachea (cartilage rings have opening posteriorly) Important to know if FB is button battery! · Must be removed emergently (within 6 hours) Objects larger than 2.5cm wide and 5cm long (unlikely to pass through pylorus)
2 week old baby with blood in stools. Thriving and breastfed. Most likely diagnosis:
a. Meckel’s)
b. cow’s milk protein allergy
c. colitis
d. anal fissure (also possible answer)
CMPA
(2% of the population, 2ft of the ileocecal valve, before 2 years of life
2 days of fever and cough, mother concerned with yellow eyes. No abdo pain. Indirect bili 58, direct 9, ALT 40, AST 42, Normal wbc. What do you do?
a. Do nothing
b. HIDA ?
c. Direct Coombs
do nothing
Direct bili 15% of indirect (threshold >20% for worrying about conjugated hyperbilirubinemia)
Assuming this is not a neonate, they are most likely getting at Gilbert syndrome (elevation of predominantly unconjugated bilirubin during times of illness or stress). LFTs basically normal. Would have liked to see Hgb to make sure no concern for hemolysis, then DAT may have been correct.
Early adolescent presenting with jaundice, indirect hyperbili (bili 56), fever. what to do?
a. Hep A, B, C serology
b. blood smear
c. do nothing
nothing - likely gilbert
viral hepatitis presents with elevated conjugated bilirubin
2 ½ year old boy in for routine check-up. Mom mentions he has had 2 episodes of rectal prolapse, reduced in the ER, in the last 6 months. You should:
a. reassure
b. treat for constipation
c. check for CF
CF
Rectal prolapse occurs most often in infants with CF, less commonly older children. Can usually be replaced manually by continuous pressure with child in knee-chest position, sedation may be helpful. Can be caused by cough, steatorrhea, malnutrition. Ensure adequate enzyme replacement, decrease fat and roughage in diet, stool softener, control of pulmonary infections. Occasionally recurrent and require sclerotherapy or surgery.
Nelson’s p. 1899: Most cases idiopathic, between 1 and 5 yo. Predisposing factors include parasites, malnutrition (i.e. CF), diarrhea, UC, chronic constipation, Ehlers-Danlos, CF, pertussis.
Girl with rectal prolapse x 2 reduced easily in the ER. What do you do?
a. reassure mom
b. observe and follow in 3 months
c. sweat chloride
d. barium enema
c. sweat chloride
3 month old with constipation since birth and poor weight gain. Rest of exam is normal. What next?
a. TSH
b. rectal biopsy
c. sweat chloride
TSH
Early symptoms may include widely open fontanelles, prolonged unconjugated jaundice, poor feeding, large tongue, umbilical hernia, respiratory difficulties. There may be constipation that does not respond to conventional treatment.
3 mo term baby with weight loss, now <5th percentile. Infrequent stools since birth. The only thing on physical exam is some abdominal distension. You do what?
a. TSH, T4
b. Sweat chloride
c. Rectal biopsy
d. Observe and f/up in 3 months
TSH
A 13 year old girl with intermittent cough and early morning throat pain. Parents comment that she has had bad breath. What would you do?
a. upper GI
b. abdominal U/S
c. CXR
d. pH probe
pH probe
- Alpha-1 antitrypsin. Most likely presentation in children?
a. jaundice
b. emphysema (late finding)
c. bronchiectasis (not typical of this disease)
d. pneumonia
=
jaundice
Liver disease more common in children vs. lung disease. Liver disease has wide presentation including silent hepatomegaly, chronic hepatitis, cirrhosis.
- Teenager with weight loss, poor appetite, anal fissure. What to do?
a. colonoscopy
b. upper GI series
colonoscopy
3 month old with constipation since birth, ftt and abdominal distension. No other things on exam. What do you do for diagnosis –
a. CF testing
b. rectal biopsy
c. T4, TSH
rectal bx
- Picture of emaciated child with ftt and muscle wasting (it is celiac). Best test for dx?
a. immunoglobulins
b. small bowel bx
smal bowel bx
Celiac- a 9-24 month old child with FTT, diarrhea, abdominal distention, muscle wasting and hypotonia. Slow growth, weight before height. May be generalized lack of subcutaneous fat with wasting of buttocks, shoulder girdle and thighs. Edema, rickets and clubbing may be seen. Many patients present much more subtly and at an older age.
Anti-TTG + total IgA (to ensure no selective IgA deficiency) is currently recommended for initial screening, highly sensitive and specific for Celiac. Definitive diagnosis requires multiple small bowel biopsies via endoscopy while the patient is on a gluten-containing diet. Biopsies may show number of abnormalities including villous atrophy, elongated crypts, increased crypt mitoses, increased intraepilethial lymphocytes, absence of brush border.
What is the most likely cause of childhood functional abdominal pain?
a. Mild inflammation
b. Lack of lactose digestion
c. Slow motility with increased visceral pain response
slow motility with inc visceral pain response
Rome III criteria for functional abdominal pain (Nelson’s p. 1884):
Must occur at least 1x/week for 2 or more months:
· Episodic or continuous pain
· Insufficient criteria for other functional GI disorders
· No evidence of inflammatory, neoplastic, anatomic, or metabolic process to explain symptoms
*If all above satisfied and one or more of the following present at least 25% of time, becomes functional abdominal SYNDROME:
· Some loss of daily functioning
· Additional somatic symptoms such as headache, limb pain, difficulty sleeping
Child who lives on a farm presents with abdominal pain and diarrhea. His small bowel follow through reveals narrowing of his distal ileum. Which of the following organisms would be important to rule out prior to getting a colonoscopy.
a. Entamoeba histolytica - tropical, can get liver abscesses, bloody diarrhea
b. Campylobacter
c. Yersinia (potentially this one as well??)
d. Shigella
yersinia
Y. enterocolitica include pigs, rodents, rabbits, sheep, cattle, horses, dogs, and cats, with pigs being the major animal reservoir.
could also be campylobacter-ingestion of contaminated poultry (chicken, turkey) or raw milk and less commonly from drinking water, pets (cats, dogs, hamsters), and farm animals.
1 month old with normal physical but total bilirubin 280 and direct 200. Hemoglobin 98 and MCV 95. Most likely cause?
a. breast feeding jaundice -
b. Haemolytic -
c. neonatal hepatitis
d. Galactosemia -
neonatla hepatitis
heme/breast feeding is uncong
Baby with bili of 280 and conjugated 200? What is the most likely cause based on incidence?
a. Breasfeeding jaundince
b. Hemolysis ABO
c. Neonatal hepatitis
d. Galactosemia
neonatal hepatits
the other most common is BA
- A child with intussesception has melanotic lesions on his lips. What is the most likely diagnosis?
a. Peutz Jegers
b. HUS
c. HSP
peutz jegers
rare autosomal dominant disorder characterized by mucocutaneous pigmentation and extensive GI hamartomatous polyposis. Macular pigmented lesions may be dark brown to dark blue and are found primarily around the lips and oral mucosa, although these lesions may also be found on the hands, feet, or perineum. Lesions can fade by puberty or adulthood. inc risk of Gi and extraintestinal malignancy
6y M has always lived on a farm. For the last 3 months he has had intermittent fever, vomiting, diarrhea and weight loss. A test shows narrowing of distal ileum. Which is the causative agent?
a. Entameoba histolytica -
b. Yersinia -
c. Salmonella -
d. Giardia
Yersinia and Giardia
giardia- Children who are exposed to G. lamblia may experience asymptomatic excretion of the organism, acute infectious diarrhea, or chronic diarrhea with persistent gastrointestinal tract signs and symptoms, including failure to thrive and abdominal pain or cramping.
salmonella common clinical presentation of salmonellosis is acute enteritis. After an incubation period of 6-72 hr (mean: 24 hr), there is an abrupt onset of nausea, vomiting, and crampy abdominal pain, located primarily in the periumbilical area and right lower quadrant, followed by mild to severe watery diarrhea, resolve within 7d
Boy has had inflamed, ulcerated lips and gums. (Picture shown). Which of the following conditions is this more likely to be seen with?
a. Chronic mycoplasma infection
b. IBD
c. Eosinophilic gastritis
d. Contact dermatitis
IBD
Picture of child with swollen, cracked, dry and ulcerated lips for 2 months. What condition is usually associated with this finding?
a. Contact dermatitis
b. Eosinophilic gastroenteropathy
c. Crohn’s
d. Recurrent Chlamydia infection
chrons
4 month old child with puffy eyes, albumin of 14, urine negative for protein. Looks well. On an unrestricted diet. How would you treat? (no mention of any GI symptoms in the question)
a. Prednisone
b. High protein, high calorie diet
c. Protein hydrolysate formula
d. IV albumin
for protein losing enteropathy
protein hydrosolate formulareatment includes restricting the amount of long-chain fat ingested and administering a formula containing protein and medium-chain triglycerides (MCTs). Supplementing a low-fat diet with MCT oil in cooking is used in the management of older children with PLE
- considered in patients with hypoproteinemia in whom other causes, such as malnutrition, heavy proteinuria, and impaired protein synthesis due to liver diseases have been excluded. The mainstay of dietary therapy is a low-fat, high-protein, medium-chain triglyceride (MCT) diet. The diet can be supplemented by commercially available protein formulas.
- Child with hepatitis, initially elevated ALT and AST but now resolving. What is the best thing to follow
a. INR
b. GGT
c. ALT, AST
d. albumin
INR
Synthetic dysfunction is reflected by a combination of abnormal protein synthesis (prolonged prothrombin time, high international normalized ratio, low serum albumin levels), metabolic disturbances (hypoglycemia, lactic acidosis, hyperammonemia), poor clearance of medications dependent on liver function, and altered sensorium with increased deep tendon reflexes (hepatic encephalopathy).
A child has resolving viral hepatitis. AST and ALT have normalized. Bilirubin is still elevated. Which of the following is best to monitor serially:
a. GGT
b. INR
c. Albumin
d. Abdo ultrasound
INR
rise in serum levels of alanine aminotransferase (ALT) and aspartate aminotransferase (AST). The magnitude of enzyme elevation does not correlate with the extent of hepatocellular necrosis and has little prognostic value. There is usually slow improvement over several weeks, but AST and ALT levels lag behind the serum bilirubin level, which tends to normalize first.
A child presents after having been witnessed to swallow a nickel. X-ray confirms the coin is in the stomach. What do you do?
a. Notify surgery for urgent laparotomy
b. Admit, repeat x-ray in 3 days
c. Notify GI for endoscopic removal
d. Observation only
observe
coins that reach the stomach can be managed expectantly, and most will pass out uneventfully within one to two weeks. For these patients, most providers check the location of the coin with a plain radiograph about once a week. If the coin has not passed beyond the stomach by four weeks, endoscopic removal i
A 13 month old boy has a diaper rash and diarrhea for the last few months, since his parents have been introducing new foods. Which of the following is correct?
a. do skin testing and RAST
b. Carbohydrate intolerance is common at this age
c. He is now sensitized to cow’s milk protein
CH intolerance is common at thsi age
Todder’s diarrhea -6 and 40 months of age often following a distinct identifiable enteritis and treatment with an antibiotic. Loose, nonbloody, stools (at least 2 per day but usually more) occur without associated symptoms of fever, pain or growth failure. Malabsorption is not a key feature. Multiple causes may be present: over-consumption of fruit juices, relative intestinal hypermotility, increased secretion of bile acids and sodium, and intestinal prostaglandin abnormalities. Treatment consists of reassurance, careful growth assessment, and psyllium bulking agent
- Teen girl with weight loss, vomiting, fistula in ano. (No diarrhea, but makes it really sound like Crohn’s). What test to make diagnosis?
a. Ultrasound or CT (I forget)
b. Colonoscopy
c. Upper GI series
colonscopy
- Patients with IBD lose weight primarily due to:
a. increased metabolic demands
b. inadequate nutrient intake
c. malabsorption
inadequate intake
11 year old girl with vague abdominal pain, vomiting, and jaundice. Her labs show ALT 1000, total bilirubin 100. What test will likely confirm the diagnosis?
a. Hep A IgM
b. CMV urine
c. Heb B serology
d. monospot
Hep A
an acute, self-limited illness associated with general, nonspecific symptoms, such as fever, malaise, anorexia, vomiting, nausea, abdominal pain or discomfort, and diarrhea. During the prodromal period, aminotransferases are typically elevated. Jaundice (conjugated hyperbilirubinemia) usually occurs one week after onset of symptoms, along with choluria (bilirubin in the urine) and mild hepatomegaly.
3 week old infant has jaundice. His birth weight was 3250g and he now weighs 3490g. He is breastfeeding well. Hemoglobin is 127 and total bilirubin is 270, conjugated bilirubin is 8. Coombs test is negative. What should be done?
a. Admit for phototherapy
b. Referral to gastroenterology
c. Reassess in 1 week
d. Recommend switching from breastfeeding to formula
?reassess 1 w
breast milk jaundice?
A 2 yo is in the ER with bright red rectal beeding. He is pale-looking but otherwise well. He does not appear to be in any discomfort. On rectal exam, you find blood mixed with stool on your glove. Hemoglobin is normal. What is the most likely diagnosis?
a. ulcerative colitis
b. Meckel’s diverticulum
c. Anal fissures
meckles
incomplete obliteration of the vitelline duct leading to the formation of a true diverticulum of the small intestine. Usually asymptomatic but can cause abdominal pain or symptoms of gastrointestinal bleeding or bowel obstruction.
Meckel’s diverticulum should be suspected in:
Children with painless lower gastrointestinal bleeding
Children with intussusception, particularly recurrent intussusception
Patients with features of acute appendicitis, particularly when the appendix has already been removed
two years of age. It is often referred to by the rule of 2’s; 2% of the population, within 2 feet of the ileocecal valve, 2 inches in length, tow types of heterotopic Mucos
6 mo baby with FTT is very irritable. Was breastfed initially and solids were introduced at 4 months of age. What is the likely diagnosis?
a. Celiac disease
b. CF
c. Cow’s milk allergy
celiac
6 and 24 months of age, after the introduction of gluten into the diet. The children have chronic diarrhea, anorexia, abdominal distension and pain, and failure to thrive or weight loss; some may also have vomiting. If the diagnosis is delayed, children may present with signs of severe malnutrition. Severely affected infants may present with a celiac crisis and the hemodynamic and metabolic consequences of dehydration
What is most useful intervention in treating encopresis?
a. pharmacologic
b. behavioural
c. pharmacologic and behavioural
d. Biofeedback
pharmacologic
Biofeedback with ARM can be used for select individuals who experience chronic withholding and anismus/anorectal dyssynergia, which is the paradoxic increase in external sphincter tone while trying to defecate.
What is the most common presentation of alpha 1 antitrypsin in children?
a. Jaundice
b. Emphysema -
c. Bronchiectasis
jaundice
alpha 1 antitrypsin is an autosomal recessive disorder that causes lung and liver disease.
In the liver: accumulation of mutated alpha 1 antitrypsin
In the lung: lack of alpha 1 antitrypsin leads to unregulated leukocyte elastase leading to destruction of alveolar walls and emphsema.
Common presenting symptoms: neonatal cholestasis, hepatomegaly and chronic hepatitis. RARE to have lung disease in children
. 2yo suspected of having Celiac. What is the definitive test for celiac disease
a. Anti transglutaminase antibody
b. Jejunal biopsy
c. Gluten free diet trial
d. Antigliadin antibody
jejenual bx Multiple small bowel bx via endoscopy while the patient is on a gluten containing diet is the definitive test for celiac disease. Villous atrophy Elongated crypts Increased crypt mitoses Increased intraepithelial lymphocytes Absence of brush border Disorganization and flattening of columnar epithelium.
7 year old with sore throat in the mornings, bad breath, chronic cough with abdominal pain for 2 weeks. Her cough is worse with activity. What test will give you the diagnosis?
a. Throat swab
b. Pulmonary function tests with methacholine challenge
c. pH probe
d. Upper GI series
pH probe
Alpha 1 antitrypsin in children presents usually with
a. Cirrhosis
b. Emphysema
c. Pneumothorax
cirhosis
4 week baby presents with poor feeding and poor weight gain. He is jaundiced and has hepatosplenomegaly. His bilirubin is 150 with conjugated 100. Which imaging test would you do next?
a. U/S with dopplers
b. MRI
c. CT abdomen
d. Dis HIDA scan / Nuclear med biliary excretion scan
u/s with doppler
. The most important factor as to why patients with IBD lose weight is
a. Inadequate/poor intake
b. Increased metabolic demands / increased energy requirements
c. Malabsorption
d. Rapid transit time
dec intake
Baby with delayed meconium passage, abdo distension and calcifications on AXR
a. Hirschprungs
b. CF
c. Duodenal atresia – “double bubble” would be seen in on AXR, usually present with bilious vomiting on the first day of life. Hx of polyhydramnios present in ½ pregnancies.
CF
Abdominal distention, failure to pass meconium and emesis present in the first 24-48 hours in babies with CF.
· AXR: dilated loops of bowel, air fluid levels, frequently collection of ground glass material in the lower central abdomen.
· Rarely, meconium peritonitis (intrauterine rupture of the bowel) can be detected with the presence of peritoneal or scrotal calcifications.
12 month old child who has passed 3 soft red stools in the past 12 hours. He is asymptomatic. The same thing happened 4 months ago but resolved. His Hb is now 70. Investigation?
a. Upper endoscopy
b. UGI series
c. Nuclear med scan for ectopic gastric tissue
Nuclear med scan for ectopic gastric tissue
Meckel radionuclide scan, performed after IV administration of technetium 99m pertechntate.
· Update can be enhanced by ranitidine, glucagon
· False negative in anemic patients
· Radiolabeled tagged red blood cell scan can be used but the patient must be actively bleeding
Child swallowed a coin and it is in the stomach on X-ray. What do you do?
a. Repeat X-ray in 2 days
b. Consult surgery
c. Observe
d. Give him a pro-motility agent
OBSERVE\
Coins lodged in the esophagus can be observed up to 24 hours in anticipation of passage into the stomach.
A child has resolving viral hepatitis. AST and ALT have normalized. Bilirubin is still elevated. Which of the following is best to monitor serially:
a. GGT
b. INR
c. Albumin
d. Abdo ultrasound
e. Alk phos
inr
The magnitude of the enzyme elevation does not correspond with the degree of hepatocellular necrosis and has little prognostic value.
o AST and ALT levels tend to lag behind serum bilirubin levels, which tend to normalize first.
o Rapidly falling ALT levels can predict a poor outcome, particularly if their decline coincides with a rising bilirubin and prolonged thrombin time.
· Serum conjugated bilirubin levels:
o Results from abnormal bile flow at the cellular level arising from hepatocyte damage.
· Altered synthetic function:
o Most important marker of liver injury
o Abnormal synthetic liver function is a marker of liver failure and is an indication from prompt referral to a transplant centre.
o Prolonged PTT, INR, low albumin, hypoglycemia, lactic acidosis and hypermmonemia and hepatic encephalopathy are markers of altered synthetic function.
- What is the most specific test for pancreatitis:
a. Amylase
b. Lipase
c. Abdo U/S
d. Abdo CT scan
e. AXR
lipase
· Lipase peaks at 24-48 hours and remains elevated for 8-14 days longer
. 13 year old with early morning throat pain. She also has some cough with exercise. Parents comment that she has bad breath. What would you do:
a. upper GI
b. Abdo u/s
c. CXR
d. pH probe
pH probe
A mother brings in her 13-month-old child because he seems to have been getting a diaper rash and diarrhea with the introduction of new foods over the past couple months
a. arrange for skin testing and RAST
b. it is due to sensitization to cow’s milk protein
c. carbohydrate intolerance is a common cause
d. citrus fruits and tomatoes can cause this via an immune mediated mechanism
e. if mucous is not present in the stool then it cannot be an immune problem
carbohydrate intolerance is a common cause
. 14 yo black boy with one year history of post-prandial intermittent abdominal pains. Normal stools. No bloating. No vomiting. What test do you do?
a. hemoglobin electrophoresis
b. Hydrogen breath test
c. Gastroscopy with biopsy
d. UGI/SBFT
e. Abdo ultrasound
hemoglibin electropheoresis
. Sexually active adolescent female with sickle cell disease and a history of previous transfusions presents with an acute history of fever, jaundice and vomiting. She also develops right shoulder pain. Hb 79 (prev 89), AST and ALT slightly elevated. Unconjugated bilirubin is increased. What is the most likely diagnosis?
a. fitz hugh Curtis
b. Cholecystitis
c. hepatitis C –
d. HIV
e. vasoocclusive disease of the liver
a. fitz hugh Curtis
- perihepatitis gaused by gonorrhea or chlamydia. Should present with RUQ tenderness, R shoulder pain can be a manifestation of fitz hugh Curtis.
b. Cholecystitis (this would be conjugated)
c. hepatitis C – occurs more insidiously, but she has had multiple transfusions.
d. HIV
e. vasoocclusive disease of the liver (hepatic or post hepatic)
What is true regarding extrahepatic portal hypertension:
a. associated with hepatomegaly
b. associated with splenomegaly
c. Liver transaminases will be abnormal
d. most common cause is splenic vein thrombosis –
SPLENOMEGALY
– bleeding from esophageal varices is the most common presentation of portal HTN, second most common presentation is splenomegaly sometimes associated with hypersplenism.
. Which of the following is true?
a. the prevalence of GER documented by esophageal PH monitoring is estimated to be 10% in first year of life
b. regurgitation of at least one episode a day occurs in all of 10-12 months old -40% of healthy infants have one episode of spitting up per day.
c. the natural hx of GER is improvement with introduction of the solid food
d. the natural hx of GER is associated disappearance of symptoms in 98% by 15m
the natural hx of GER is associated disappearance of symptoms in 98% by 15m (95-98% by 18 months of age)
A 10y old boy has been having belly aches for about 2y .They occur at night as well during the day. Occasionally he vomits after onset of pain. OB +ve in stool. His father also gets frequent stomach aches :
a. appendicitis
b. Meckel’s diverticulum
c. peptic ulcer
d. UC
peptic ulcer
. First line of therapy in GER :
a. Antacids
b. metoclopramide
c. omeprazole
d. ranitidine
ranitidine
A sexually active adolescent female with sickle cell disease and a history of previous transfusions presents with an acute history of fever, jaundice and vomiting. She also develops right shoulder pain. Hbg 79 (prev 89), AST and ALT slightly elevated. Unconjugated bilirubin is increased. What is the most likely diagnosis?
a. Fitz-Hugh-Curtis
b. cholecystitis
c. hepatitis C
d. HIV
e. vaso-occlusive disease of the liver
a. Fitz-Hugh-Curtis
b. cholecystitis
15 year old with h. pylori. You should treat with:
a. h2 blocker
b. amox, clarithro and proton pump inhibitor
c. clarithro and h2 blocker
d. amox and proton pump inhibitor
amox, clarithro and proton pump inhibitor
13 year old with early morning throat pain. Parents comment that she has bad breath. What would you do:
a. upper GI
b. Abdo u/s
c. CXR
d. pH probe
ph probe
2 year old in the ER with passage of bright red blood mixed in with his stool. Pale looking but otherwise okay. On rectal exam you find blood mixed with stool on your glove. Hemoglobin is 94. Most likely diagnosis:
a. anal fissure
b. bleed from a peptic ulcer
c. Meckel’s diverticulum
meckels
